HOW TO MAKE A CASE STUDY

ALMERIA, Krishna Rae Z., BERNARDO, Ryan Angelo, DE LOS SANTOS, Janet Alexis A., MENESES, Raza Crecia L., PEREZ, Ana Aumpta P., RUSSELL, Glynda

A case presentation should only include information that pertains to the case and refrain from providing confusing and superfluous data. Daily patient progress including normal VS, routine laboratory results, typical consultations with other disciplines, stepdown transfer to wards, and other irrelevant patient information MUST BE AVOIDED.

OUTLINE
I. II. III. IV. V. VI. ABSTRACT INTRODUCTION COMPREHENSIVE NURSING HEALTH HISTORY PHYSICAL EXAMINATION LABORATORIES & DIAGNOSTIC PROCEDURES ANATOMY & PHYSIOLOGY

VII. VIII. IX. X. XI. XII. XIII.

PATHOPHYSIOLOGY SUMMARY OF CLINICAL FINDINGS PHARMACOLIGICAL SHEET NURSING CARE PLAN DISCHARGE PLANNING PROGNOSIS BIBLIOGRAPHY

ABSTRACT
Composed of 100-250 words
Should include 4 sections as the main text in a succinct form: Introduction and objective, Case Presentation, discussion and conclusion.

INTRODUCTION
Written concise and salient and not more than 3 paragraphs and need not be labeled with a heading. Should provide the background information that present clarity to the subject of discussion.
The introduction should provide the subject, purpose and merit of the case report.

 Statistical records : LOCAL, NATIONAL, INTERNATIONAL

Focused comprehensive literature review

Citations should be chronological

1-2 sentences description of the patients case as a segway to the CASE PRESENTATION.

COMPREHENSIVE NURSING HEALTH HISTORY

A. Biographic Data
B. Chief Complaint C. History of Present Illness D. Past Medical History E. Family History F. Functional Health Patterns

FUNCTIONAL HEALTH PATTERN

10

11

1z

PHYSICAL EXAMINATION
Cephalocaudal
Narrative

Should be written by following the format:

IPePaA IAPePa

LABORATORIES and DIAGNOSTIC EXAMS

All laboratories (current and relevant) should be presented in a tabular form.
NAME OF PROCEDURE Parameters Normal Value Patients value Interpretatio n Significance

Diagnostics: Impression and Results

ANATOMY AND PHYSIOLOGY

Content should be concise and straight to the point and should only focus on the area or organ involved
An illustration or a picture should be presented

PATHOPHYSIOLOGY
A. SCHEMA

B. NARRATIVE (explanation of the flow chart)

Definition:

Gives rise to symptoms that are reported by

patients/signs that are observed by patients or nurses or other health care providers

OBSERVATION + PHYSIOLOGY +
PATHOPHYSIOLOGY

 Be able to explain processes in their own words

and translate these processes into technical vocabulary Explain by drawing processes, perhaps by flow charts or map format. Label key steps and use

colors to emphasize main points

Ask yourself why? and whats the consequence? Relate what youre learning to what you ALREADY know about physiology

SUMMARY OF CLINICAL FINDINGS AND MANIFESTATIONS

A table of summary of clinical findings and manifestations should be written after the

narrative pathophysiology.
Both POSSIBLE and ACTUAL MANIFESTATIONS are recorded provided that the former is emphasized/highlighted or otherwise written in two columns

PHARMACOLOGICAL SHEET
Should be patient focused. All medications of the patient should be written in a pharmacological sheet

HEADERs should be written on each page of

the pharmacological sheet:
a. Name of Patient b. Age and Sex c. Attending Physician d. Chief complaint

NURSING CARE PLAN

Is best thought of as a written reflection of the nursing process. (Gulanick/Myers)
Is a written or computerized guide that organizes information about the clients care. (Kozier)

DISCHARGE PLANNING
A. For patients with non complicated disease and
no surgeries in the ward and private areas:

edications

E
T H

xcercise
reatment and Visits ealth teachings /Hygeine

O
D S

bservable signs and symptoms

iet piritual / Support System

B. For patients who are post operative:

H A S ealth teachings anticipatory Guidance piritual Care

M
I N

edications
ncision or wound care utrition

nvironment

C. For patients with post delivery and post CS

B reast

U
B B

terus
ladder owel

L
E S H E

ochia
pisiotomy upport system / Spiritual omans sign motional

PROGNOSIS
May be written according to the students interpretation of the patients case
If there are prognosis written by the health team, it is encouraged to include it as an input.

BIBLIOGRAPHY
Family name, name of author, TITLE OF REFERENCE. Publisher. Year published.
Alphabetically arranged and categorized according to:
a. Books b. Journal c. Websites